DM2 ADVANCEMENT TO INSULIN: When Patient Fails Oral Rx Patty Glatt, MD 10/09 I. Initiating Single Basal Injection
Describe to patient as the "background" amount of insulin needed to run the fuel cells of their body's motor; Mealtime insulin is the extra insulin needed to handle the calories eaten. ·Add Basal “Background” insulin to oral regimen when A1C> 7.5-8.0 or FBS> 130 on maximum optimal oral regimen. Early use reduces CV/macrovascular complications. Single basal dose sufficient when FBS elevated but orals control postprandial ·Basal therapy offers opportunity for patient efficacy, establish control FBS, transition to prandial and MDI insulin. ·Oral DM agents: Continue MTF for weight control and insulin resistance. Caution w/TZD with insulin may ↑CHF. SU: Usually ↓ reduce to ½ max dose or DC.
BLOOD GLUCOSE GOALS ON HOME MONITORING Before meals: 90-130:w/o significant hypoglycemia 120-180: for elderly or patients with hypoglycemic unawareness 80-100: for those desiring tighter physiologic control After meals: under 160; Recommended under 135 Bedtime: under 180; Recommended under 130 Basal Insulin Treat to Target (T2T) Protocol: Achieves quicker A1C control with patient-driven titration. Avoids hypoglycemia GOAL: Titrate to FBS 90-130 mg/dl. (May adjust to tighter goal ≤110 individually per MD outside of protocol) How? 1. Start with minimum 10 units once daily Lantus/Glargine®, or Levemir/Detemir® or use guideline below to guide decision. For 100kg, on average needs 40-50 units ultimately. Some start at 50% calculated for T2T. 2. ↑ by 2 units until FBS <130; Option to ↑ by 4 units for FBS >180. When? ↑ insulin dose every 3-4 days (“twice a week- patient picks”) Warn:Hypoglycemia: ↓ by 4U or 10-15% if pre-breakfast glucose <70 or 2AM < 100
CALCULATING BASAL INSULIN DOSE (Usually dosed at bedtime) 0.5 U/kg normally 0.3 U/kg if concerned about risk of hypoglycemia (elderly, impaired renal, cardiac or hepatic function) 0.7 U/kg for presumed high insulin resistance (obesity, post-CABG, open wounds) II. Moving Beyond Single Basal Dosing After Basal T2T goal is reached, if HgbA1C remains >8.0, on add pre-meal "Prandial" insulin PREMIXED INSULIN(Humalog ®75/25 or Novolog ®70/30): Advantage of Premixed Insulins ·For patients unable to manage multiple dose injections for whatever reason ·Improved control when Basal insufficient Disadvantages of Premixed Insulins ·Must eat at regular times and consistent calories; Skipping meals may lead to hypoglycemia ·Premixed insulin offers no flexibility in adjustment of rapid portion
PREMIXED INSULIN OPTIONS: 1.) Switch to single Premixed before dinner. Titrate Premixed T2T to 2hrpost prandial BS (based on start of meal).Best when mostly elevated FBS and dinner or as initial Pre-mix when dinner is highest meal. 2.) Advance to BID premixed Humalog®75/25 or Novolog ®70/30.Calculate TDD. Equally split between the prebreakfast and predinner injections. Adjust according to SMBG. Occasional use for Humalog®50/50 for PM dose when more PM prandial insulin needed 3.) AM Premixed Humalog ®75/25 or Novolog ®70/30 or NPH+Lispro(Humalog®) and PM (dinner or HS) NPH When most elevations are daytime only. III. MDI (Multi-Dose Injection) Basal +Bolus Regimen: Add pre-meal (Humalog®)Lispro, (Novolog®)Aspart, or (Apirdra)Glulisine® to single meal; start with largest meal. Gradually add additional largest meals, one at a time, until control. T2T for each prandial rapid insulin to 2hr postprandial. Features: ·Test glucose before meal and 2 hours after meal (from first bite) being targeted. Adjust twice a week until readings are within 40mg/dl of each other or goal achieved ·Basal insulin Glargine usually given at bedtime. Adjust until FBS at target ·Rapid-acting Lispro (Humalog) before each meal. May start with highest meal. ·Add supplemental Lispro(Humalog)meal bolus insulin ( see Correction Factors below) if above target before giving prandial insulin
Benefits ·Can be used with Type 2 DM and Type 1 ·Assoc w/ improved glycemic control leading resulting in less microvascular ds ·Patient not tied to rigid eating schedule as with fixed-split ·Elimination of dietary restrictions for those who do CHO counting
Disadvantages ·Intensive management requires high level compliance and literacy to master ·Frequent testing required or learning Carb counting
Starting Basal/Bolus Insulin Regimen 1. Calculate Total Daily Dose (TDD)-see box. [Alternative: 0.25-0.3 U/kg/d] CALCULATE THE TDD: Calculate the TDD based on patient size for premixed insulin Dialysis patient (regardless if increased BMI): 0.3 U/kg/d Lean (BMI <25): 0.2 - 0.44 U/kg/d Overweight (BMI 25-30): 0.5 U/kg/d Obese (BMI >30): 0.6 -0.8 U/kg/d
2. Basal =50% of TDD, usually at bedtime; alternatively 30% TDD as NPH pre-breakfast and 20% TDD as NPH pre-dinner 3. Prandial (pre-meal) Bolus = 50% of TDD,as Lispro, Aspart, or Apirdra : 20% pre-breakfast, 10% pre-lunch, and 20% pre-dinner. Alternative:Basal 40%; Premeal = 20% each
Alternative Basal = 0.125units/kg/d Pre-Breakfast Lispro= 0.025 units/kg/d Pre-Lunch Lispro = 0.0125 units/kg/d Pre-Dinner Lispro = 0.023 units/kg/d Patient Self Adjustment Instructions: SELF ADJUSTMENT FOR PREMIX AND MDI LISPRO When? Every 3-4 days. Adjust one dose at a time, usually first targeting dinner control. Target Goal: ↑ 1-2 units until at target goal 90-130 before meals.
WHEN?Uncontrolled Pre-Meal BG→Adjust Before Breakfast Glucose→Bedtime Basal or before dinner premixed Before lunch→Before Breakfast Lispro or Breakfast premixed
2 hr after Lunch →Before Lunch Lispro insulin orBefore Lunch Premixed insulin 2 hr after Dinner→Before Dinner Lispro or BeforeDinner premixed insulin Bedtime Glucose→Before Dinner Lispro orBefore Dinner premixed
HOW MUCH?If Blood Glucose→Adjust Insulin <20 below goal→↓ dose 3 Units or 10-15% At goal→No Change over 5-10→↑ dose 1 unit over 11-19→↑ dose 2 units >20 above goal→↑ dose 3 Units
Fix lows values first. If only once or twice (not a pattern), ask about skipped meals. Adjust insulin in response to a pattern, not in response to a single abnormal value
Hypoglycemia: Review signs, symptoms, treatmentand strategies for preventing
Give patients earlyopportunity to try a “dry practice insulin injection”
Offer pen devices to patients with low vision, poor hand control, true needle phobia. Medi-Cal TAR approval feasible for all of these. PAR for CCHP.
Don’t underprescribe low dose syringes. Better to use 0.5 for T2T
NEVER THREATEN A PATIENT WITH INSULIN
CCHP limits Lantus to 60 cc/month.
Pens 5/box
IV. Pens and Needles PEN DEVICES Patient Selection:
Mental or Cognitive impairment- Approved indication
Poor eyesight- Approved indication
Poor adherence –Requires explanation for authorization
Needle Phobia –Requires explanation for authorization
Manufacturer /Product /Timing /Cost AVENTIS-SANOFI /Solostar PrefilledPen Lantus (Glargine)/ *Once daily/ HS$195 Solostar PrefilledPen Apidra (Glulisine)*/ 15 mins AC ReusuableOpticlick*Most used in EU *Order B-D Ultra Fine Needles 31g ,3/16"mini, 5/16"short; 29g 1/2" standard
NOVO-NORKDISK/Novolog® Mix 70/30 FLEXPENǂ /15 mins AC/$195 ReusableNovolog ® (Aspart) FLEXPENǂ /10 mins AC /$195 ǂOrder NovoFine 30,32 disposable needles or B-D Ultra Fine Needles 31g,3/16", 5/16";29g 1/2" standard
LILLY/ Humalog® Mix 75/25 Prefilled Pen /15 mins AC /$195 Humalog® (Lispro) Prefilled Pen /15 mins AC/$195 Humulin® N (NPH) Pen/ 30 mins AC/$140 Humulin® 70/30 (NPH/R) / 30 mins AC /$140 *Order B-D Ultra Fine Needles 31g ,3/16", 5/16";[29g 1/2" original]
“Pre-filled” pens are disposable.All supplied 3ml=300 units/ pen or cartridge; 5 pen/per box. Max delivery is 60 units max per injection, except Solostar Lantus and Opticlick with max 80 units per injection
[Innolet Device with large dial and numbers for use with Novolin ®(NPH/Reg) - soon to be discontinued]
All covered on medical plans but require Prior Authorization/ Treatment Authorization Requests
Store all unopened cartridges in refrigerator until use or expiration date; Store open unrefrigerated pen cartridges for 10-14 days.
Good cost alternative are Prefilled Syringes for selective patients e.g. learning impaired, family members
NEEDLES Gauge:Thinness. Higher number refers to finer needle. Order highest gauge available for patient comfort 30, 31 (“microfine”) gauge: needles are painless Lengths:Thin patients can use shorter needles. Obese patients need longer needles. 1/2" Standard ( comes in 29, 30, 31 gauge) for more obese patients 5/16” Short ( comes in 28, 29, 20, 31 gauge) for thinner patients 3/16" MiniMay be most comfortable for the Volume: Don’t underprescribe.Patient may not exceed their monthly insurance allotment 0.3cc =Low dose - up to 30 units. Best visibility if low dose used. May exceed dose if T2T pt. 0.5cc= Low dose- up to 50 units. Best for starting T2T to avoid running out of syringes 1.0 cc = Standard- up to 100 units. Best if obeseT2T and likely will need high dose V. Talking Points: OVERCOMING BARRIERS TO STARTING INSULIN TX ·Educate early that diabetes is a progressive disease; prepare your patient that most patients will eventually need insulin. ·Oral medication only work when the body makes enough insulin. ·Starting Insulin early is about reducing complications over 10years (death, MI, Stroke, amputation). We can all agree on a goal to live a long healthy life. ·Insulin allows a person the freedom to eat a relatively “normal” diet again ·Insulin is the only “natural therapy” we have ·Just one shot a day of insulin may be sufficient ·Insulin does not require refrigeration ·Starting insulin does not cause complications; untreated advanced disease does. ·INSULIN ALWAYS WORKs VI. Addendum Bolus Pre-prandial Insulin Correction Dose Calculating the Insulin Sensitivity Factor: Adjust blood glucose before/between meals as needed for deviations from goal. Approximation if patient is not well controlled on current insulin regimen.
"RULE OF 1800" For patients well controlled, use the Rule of 1800 for a more precise patient-specific value. This is the amount of Lispro needed to bring current BG down to target BG.
“Rule of 1800” Insulin Sensitivity Factor: To estimate expected drop in blood glucose for each unit of Lispro insulin, use the “1800 Rule” [Feasible to calculate only when pt. in reasonable control on known insulin regimen] 1.) To calculate the Correction Factor: Divide 1800 by total current Total Daily Dose insulin (TDD)= glucose mg/dl point drop for every unit of Lispro insulin. 2.) Current BG – Target BG (110)= # points over target. 3.) Divide this by “correction factor” (round # as needed).
INSULIN:CARBOHYDRATE CORRECTION FACTOR ·To estimate the insulin required to cover the carbohydrate load of an upcoming meal. (CHO counting). Method used for intensive Bolus + 3X Prandial ·Package labels and food lists with carbohydrate grams and portions sizes assist with this. I:C ratio is the amount of carbohydrate covered by one unit of rapid-acting insulin analog (Lispro, Aspart).The insulin-to-carbohydrate ratio can be determined using the 500 rule (see below), in which the total daily dose of insulin (TDD) is divided by 500. Typically, insulin-to-carbohydrate ratios are in the range of 1U: 10-15 gram of carbohydrate. This method can be modified for patients who prefer a simpler method of counting carbohydrates or food intake. Patients round their carbohydrate choices to a 15 g portion size and count their carbohydrates in denominations of portions rather than grams. An example would be 1 unit of insulin per 1 portion of carbohydrate.
The Carbohydrate Coverage “500 Rule”: Gives an approximation for how many grams of CHO will be covered by 1U of Lispro insulin. Divide 500 by the TDD of insulin (basal + bolus) to determine how many grams of carbohydrate will be covered by 1U of Lispro. This is this individuals “correction factor”.
EXAMPLES OF CORECTION FACTORS Calculating Carbohydrate Coverage with “500 rule” Example: Pt uses total 30 units per day (15 units Glargine and 15 units Lispro): 500/30= 17 grams carbohydrate covered by 1 unit of Lispro Therefore, for this patient, there CHO: Lispro insulin ratio is 17:1
Calculating Insulin Sensitivity Factor- Example: Joe typically uses 30 units of glargine at bedtime, 10 units of lispro at breakfast, 5 units at lunch, and 15 units at dinner. TDD= 30glargine = 30lispro = 60 units insulin/day 1800/60 = 30 Therefore every 1 unit of Lispro should drop Joe’s blood glucose 30 mg/dl. Or stated another way, for Joe, his insulin sensitivity correction factor is 30 mg/dl for each unit of Novolog (Lispro).This can be used to estimate what supplemental dose Joe will need for a pre-meal correction dose in addition to his usual dose if his pre-meal glucose value is exceeds target value.
Calculating Bolus- Example: Joe has a tooth infection. His pre-lunch blood sugar has shot up to 240 from his usual 120. He needs a correction factor for 120mg/dl. Therefore, he needs 120mg/dl divided by 30mg/dl per 1 unit = 4 units Novolog for correction.. Therefore Joe’s dose will be his usual 5 + 4 = 9 units Novolog before eating lunch.
Example: Calculating Pre-Prandial Correction with CHO counting and Bolus Correction: By way of example, consider a patient who has a target blood sugar before meals of 110, premeal glucose of 170, insulin-to-carbohydrate ratio of 1:15, and an insulin sensitivity factor of 1:30. This person is about to eat a meal estimated to contain 60 g of carbohydrate. He currently takes a dose of Glargine/Lantus every evening and a rapid-acting analog (lispro or aspart) before each meal. With the I:C ratio of 1:15 and 60 g of carbohydrate intake, this patient would require 4 units of rapid-acting insulin to cover the carbohydrates at this meal. With a premeal glucose of 170, target glucose of 110 and a 1:30 insulin sensitivity factor, an additional 2 units would be required as the correction factor. Four units of lispro or aspart will be needed to cover the carbohydrate intake, and an additional 2 units will be needed as a correction factor based on the premeal glucose, for a total dose of 6 units of lispro or aspart.
Patty Glatt, MD 10/09
I. Initiating Single Basal Injection
Describe to patient as the "background" amount of insulin needed to run the fuel cells of their body's motor; Mealtime insulin is the extra insulin needed to handle the calories eaten.
· Add Basal “Background” insulin to oral regimen when A1C> 7.5-8.0 or FBS> 130 on maximum optimal oral regimen. Early use reduces CV/macrovascular complications. Single basal dose sufficient when FBS elevated but orals control postprandial
· Basal therapy offers opportunity for patient efficacy, establish control FBS, transition to prandial and MDI insulin.
· Oral DM agents: Continue MTF for weight control and insulin resistance. Caution w/TZD with insulin may ↑CHF. SU: Usually ↓ reduce to ½ max dose or DC.
BLOOD GLUCOSE GOALS ON HOME MONITORING
Before meals: 90-130: w/o significant hypoglycemia
120-180: for elderly or patients with hypoglycemic unawareness
80-100: for those desiring tighter physiologic control
After meals: under 160; Recommended under 135
Bedtime: under 180; Recommended under 130
Basal Insulin Treat to Target (T2T) Protocol:
Achieves quicker A1C control with patient-driven titration. Avoids hypoglycemia
GOAL: Titrate to FBS 90-130 mg/dl. (May adjust to tighter goal ≤110 individually per MD outside of protocol)
How?
1. Start with minimum 10 units once daily Lantus/Glargine®, or Levemir/Detemir® or use guideline below to guide decision. For 100kg, on average needs 40-50 units ultimately. Some start at 50% calculated for T2T.
2. ↑ by 2 units until FBS <130; Option to ↑ by 4 units for FBS >180.
When? ↑ insulin dose every 3-4 days (“twice a week- patient picks”)
Warn: Hypoglycemia: ↓ by 4U or 10-15% if pre-breakfast glucose <70 or 2AM < 100
CALCULATING BASAL INSULIN DOSE (Usually dosed at bedtime)
0.5 U/kg normally
0.3 U/kg if concerned about risk of hypoglycemia (elderly, impaired renal, cardiac or hepatic function)
0.7 U/kg for presumed high insulin resistance (obesity, post-CABG, open wounds)
II. Moving Beyond Single Basal Dosing
After Basal T2T goal is reached, if HgbA1C remains >8.0, on add pre-meal "Prandial" insulin
PREMIXED INSULIN(Humalog ®75/25 or Novolog ®70/30):
Advantage of Premixed Insulins
· For patients unable to manage multiple dose injections for whatever reason
· Improved control when Basal insufficient
Disadvantages of Premixed Insulins
· Must eat at regular times and consistent calories; Skipping meals may lead to hypoglycemia
· Premixed insulin offers no flexibility in adjustment of rapid portion
PREMIXED INSULIN OPTIONS:
1.) Switch to single Premixed before dinner. Titrate Premixed T2T to 2hrpost prandial BS (based on start of meal). Best when mostly elevated FBS and dinner or as initial Pre-mix when dinner is highest meal.
2.) Advance to BID premixed Humalog®75/25 or Novolog ®70/30. Calculate TDD. Equally split between the prebreakfast and predinner injections. Adjust according to SMBG. Occasional use for Humalog®50/50 for PM dose when more PM prandial insulin needed
3.) AM Premixed Humalog ®75/25 or Novolog ®70/30 or NPH+Lispro(Humalog®)
and PM (dinner or HS) NPH When most elevations are daytime only.
III. MDI (Multi-Dose Injection) Basal +Bolus Regimen:
Add pre-meal (Humalog®)Lispro, (Novolog®)Aspart, or (Apirdra)Glulisine® to single meal; start with largest meal. Gradually add additional largest meals, one at a time, until control. T2T for each prandial rapid insulin to 2hr postprandial.
Features:
· Test glucose before meal and 2 hours after meal (from first bite) being targeted. Adjust twice a week until readings are within 40mg/dl of each other or goal achieved
· Basal insulin Glargine usually given at bedtime. Adjust until FBS at target
· Rapid-acting Lispro (Humalog) before each meal. May start with highest meal.
· Add supplemental Lispro(Humalog) meal bolus insulin ( see Correction Factors below) if above target before giving prandial insulin
Benefits
· Can be used with Type 2 DM and Type 1
· Assoc w/ improved glycemic control leading resulting in less microvascular ds
· Patient not tied to rigid eating schedule as with fixed-split
· Elimination of dietary restrictions for those who do CHO counting
Disadvantages
· Intensive management requires high level compliance and literacy to master
· Frequent testing required or learning Carb counting
Starting Basal/Bolus Insulin Regimen
1. Calculate Total Daily Dose (TDD)-see box. [Alternative: 0.25-0.3 U/kg/d]
CALCULATE THE TDD: Calculate the TDD based on patient size for premixed insulin
Dialysis patient (regardless if increased BMI): 0.3 U/kg/d
Lean (BMI <25): 0.2 - 0.44 U/kg/d
Overweight (BMI 25-30): 0.5 U/kg/d
Obese (BMI >30): 0.6 -0.8 U/kg/d
2. Basal =50% of TDD, usually at bedtime; alternatively 30% TDD as NPH pre-breakfast and 20% TDD as NPH pre-dinner
3. Prandial (pre-meal) Bolus = 50% of TDD, as Lispro, Aspart, or Apirdra : 20% pre-breakfast, 10% pre-lunch, and 20% pre-dinner.
Alternative: Basal 40%; Premeal = 20% each
Alternative
Basal = 0.125units/kg/d
Pre-Breakfast Lispro= 0.025 units/kg/d
Pre-Lunch Lispro = 0.0125 units/kg/d
Pre-Dinner Lispro = 0.023 units/kg/d
Patient Self Adjustment Instructions:
SELF ADJUSTMENT FOR PREMIX AND MDI LISPRO
When? Every 3-4 days. Adjust one dose at a time, usually first targeting dinner control.
Target Goal: ↑ 1-2 units until at target goal 90-130 before meals.
WHEN? Uncontrolled Pre-Meal BG→ Adjust
Before Breakfast Glucose→ Bedtime Basal or before dinner premixed
Before lunch → Before Breakfast Lispro or Breakfast premixed
2 hr after Lunch → Before Lunch Lispro insulin or Before Lunch Premixed insulin
2 hr after Dinner→ Before Dinner Lispro or Before Dinner premixed insulin
Bedtime Glucose→ Before Dinner Lispro or Before Dinner premixed
HOW MUCH? If Blood Glucose→ Adjust Insulin
<20 below goal→ ↓ dose 3 Units or 10-15%
At goal→ No Change
over 5-10→ ↑ dose 1 unit
over 11-19→ ↑ dose 2 units
>20 above goal→ ↑ dose 3 Units
TARGET GOALS:
FBS, PREMEAL ≤ 130 ≥90 , Recommended ˂100
2 HR POSTPRANDIAL ˂160 -135; recommend goal ˂135
BEDTIME ˂130
HYPOGLYCEMIA ANY ˂70
http://care.diabetesjournals.org/content/32/1/193.full.pdf+html
http://clinical.diabetesjournals.org/content/23/2/78.full.pdf+html
http://care.diabetesjournals.org/content/31/7/1305.full.pdf+html
MISCELLANEOUS PRACTICE TIPS
IV. Pens and Needles
PEN DEVICES
Patient Selection:
Manufacturer /Product / Timing /Cost
AVENTIS-SANOFI /Solostar PrefilledPen Lantus (Glargine)/ *Once daily/ HS $195
Solostar PrefilledPen Apidra (Glulisine)*/ 15 mins AC
Reusuable Opticlick* Most used in EU
*Order B-D Ultra Fine Needles 31g ,3/16"mini, 5/16"short; 29g 1/2" standard
NOVO-NORKDISK/ Novolog® Mix 70/30 FLEXPENǂ /15 mins AC/ $195
Reusable Novolog ® (Aspart) FLEXPENǂ /10 mins AC /$195
ǂOrder NovoFine 30,32 disposable needles or B-D Ultra Fine Needles 31g,3/16", 5/16";29g 1/2" standard
LILLY/ Humalog® Mix 75/25 Prefilled Pen /15 mins AC /$195
Humalog® (Lispro) Prefilled Pen / 15 mins AC/ $195
Humulin® N (NPH) Pen/ 30 mins AC/ $140
Humulin® 70/30 (NPH/R) / 30 mins AC /$140
*Order B-D Ultra Fine Needles 31g ,3/16", 5/16";[29g 1/2" original]
“Pre-filled” pens are disposable. All supplied 3ml=300 units/ pen or cartridge; 5 pen/per box. Max delivery is 60 units max per injection, except Solostar Lantus and Opticlick with max 80 units per injection
[Innolet Device with large dial and numbers for use with Novolin ®(NPH/Reg) - soon to be discontinued]
All covered on medical plans but require Prior Authorization/ Treatment Authorization Requests
Store all unopened cartridges in refrigerator until use or expiration date; Store open unrefrigerated pen cartridges for 10-14 days.
Good cost alternative are Prefilled Syringes for selective patients e.g. learning impaired, family members
NEEDLES
Gauge: Thinness. Higher number refers to finer needle. Order highest gauge available for patient comfort
30, 31 (“microfine”) gauge: needles are painless
Lengths: Thin patients can use shorter needles. Obese patients need longer needles.
1/2" Standard ( comes in 29, 30, 31 gauge) for more obese patients
5/16” Short ( comes in 28, 29, 20, 31 gauge) for thinner patients
3/16" Mini May be most comfortable for the
Volume: Don’t underprescribe. Patient may not exceed their monthly insurance allotment
0.3cc =Low dose - up to 30 units. Best visibility if low dose used. May exceed dose if T2T pt.
0.5cc = Low dose- up to 50 units. Best for starting T2T to avoid running out of syringes
1.0 cc = Standard- up to 100 units. Best if obeseT2T and likely will need high dose
V. Talking Points:
OVERCOMING BARRIERS TO STARTING INSULIN TX
· Educate early that diabetes is a progressive disease; prepare your patient that most patients will eventually need insulin.
· Oral medication only work when the body makes enough insulin.
· Starting Insulin early is about reducing complications over 10 years (death, MI, Stroke, amputation). We can all agree on a goal to live a long healthy life.
· Insulin allows a person the freedom to eat a relatively “normal” diet again
· Insulin is the only “natural therapy” we have
· Just one shot a day of insulin may be sufficient
· Insulin does not require refrigeration
· Starting insulin does not cause complications; untreated advanced disease does.
· INSULIN ALWAYS WORKs
VI. Addendum
Bolus Pre-prandial Insulin Correction Dose
Calculating the Insulin Sensitivity Factor:
Adjust blood glucose before/between meals as needed for deviations from goal. Approximation if patient is not well controlled on current insulin regimen.
APPROXIMATION OF INSULIN SENSITIVITY FACTORS:
Patient Characteristic → Amount ↓BG/1U Lispro
Highly insulin sensitive and/or bad kidneys→ Lower 60-100 mg/dl
Normally insulin sensitive → Lower 50 mg/dl
Mild insulin resistance BMI> 25→ Lower 30 mg/dl
Moderate insulin resistance BMI>30→ Lower 20 mg/dl
Severe insulin resistance BMI>40→ Lower <10 mg/dl
"RULE OF 1800"
For patients well controlled, use the Rule of 1800 for a more precise patient-specific value. This is the amount of Lispro needed to bring current BG down to target BG.
“Rule of 1800” Insulin Sensitivity Factor: To estimate expected drop in blood glucose for each unit of Lispro insulin, use the “1800 Rule”
[Feasible to calculate only when pt. in reasonable control on known insulin regimen]
1.) To calculate the Correction Factor: Divide 1800 by total current Total Daily
Dose insulin (TDD)= glucose mg/dl point drop for every unit of Lispro insulin.
2.) Current BG – Target BG (110)= # points over target.
3.) Divide this by “correction factor” (round # as needed).
INSULIN:CARBOHYDRATE CORRECTION FACTOR
· To estimate the insulin required to cover the carbohydrate load of an upcoming meal. (CHO counting). Method used for intensive Bolus + 3X Prandial
· Package labels and food lists with carbohydrate grams and portions sizes assist with this.
I:C ratio is the amount of carbohydrate covered by one unit of rapid-acting insulin analog (Lispro, Aspart). The insulin-to-carbohydrate ratio can be determined using the 500 rule (see below), in which the total daily dose of insulin (TDD) is divided by 500. Typically, insulin-to-carbohydrate ratios are in the range of 1U: 10-15 gram of carbohydrate.
This method can be modified for patients who prefer a simpler method of counting carbohydrates or food intake. Patients round their carbohydrate choices to a 15 g portion size and count their carbohydrates in denominations of portions rather than grams. An example would be 1 unit of insulin per 1 portion of carbohydrate.
The Carbohydrate Coverage “500 Rule”:
Gives an approximation for how many grams of CHO will be covered by 1U of Lispro insulin.
Divide 500 by the TDD of insulin (basal + bolus) to determine how many grams of carbohydrate will be covered by 1U of Lispro. This is this individuals “correction factor”.
EXAMPLES OF CORECTION FACTORS
Calculating Carbohydrate Coverage with “500 rule”
Example: Pt uses total 30 units per day (15 units Glargine and 15 units Lispro):
500/30= 17 grams carbohydrate covered by 1 unit of Lispro
Therefore, for this patient, there CHO: Lispro insulin ratio is 17:1
Calculating Insulin Sensitivity Factor- Example:
Joe typically uses 30 units of glargine at bedtime, 10 units of lispro at breakfast, 5 units at lunch, and 15 units at dinner.
TDD= 30glargine = 30lispro = 60 units insulin/day
1800/60 = 30
Therefore every 1 unit of Lispro should drop Joe’s blood glucose 30 mg/dl.
Or stated another way, for Joe, his insulin sensitivity correction factor is 30 mg/dl for each unit of Novolog (Lispro).This can be used to estimate what supplemental dose Joe will need for a pre-meal correction dose in addition to his usual dose if his pre-meal glucose value is exceeds target value.
Calculating Bolus- Example:
Joe has a tooth infection. His pre-lunch blood sugar has shot up to 240 from his usual 120. He needs a correction factor for 120mg/dl. Therefore, he needs 120mg/dl divided by 30mg/dl per 1 unit = 4 units Novolog for correction.. Therefore Joe’s dose will be his usual 5 + 4 = 9 units Novolog before eating lunch.
Example:
Calculating Pre-Prandial Correction with CHO counting and Bolus Correction:
By way of example, consider a patient who has a target blood sugar before meals of 110, premeal glucose of 170, insulin-to-carbohydrate ratio of 1:15, and an insulin sensitivity factor of 1:30. This person is about to eat a meal estimated to contain 60 g of carbohydrate. He currently takes a dose of Glargine/Lantus every evening and a rapid-acting analog (lispro or aspart) before each meal. With the I:C ratio of 1:15 and 60 g of carbohydrate intake, this patient would require 4 units of rapid-acting insulin to cover the carbohydrates at this meal. With a premeal glucose of 170, target glucose of 110 and a 1:30 insulin sensitivity factor, an additional 2 units would be required as the correction factor. Four units of lispro or aspart will be needed to cover the carbohydrate intake, and an additional 2 units will be needed as a correction factor based on the premeal glucose, for a total dose of 6 units of lispro or aspart.